Panic
Disorder
in Children
Donna
Moreau,
M.D.,
and
Objective: Panic disorder has been in children or adolescents. The authors’ f or panic attacks and/or panic disorder on the biological discuss
the
basis
possible
ofpanic
treatment
These
and
articles
included
of children and and adolescents, adolescents,
panic-like
as it has for
research disorder
ofchildren in pediatric
been
panic
studied disorder
on panic disorder in children and
histories
of adults
and
adolescents
patients,
with
at risk
family
of panic
is similar disorder
to that
found
to children
and
in adults. adolescents
studies
Conclusions: would
lthough anxiety symptoms are common in children of all ages and both sexes (1), only three anxiety disorders (overanxious disorder, separation anxiety disorder, and avoidant disorder) are classified specifically as disorders of childhood. Family studies and retrospective reports of childhood symptoms by adults with anxiety disorders suggest a continuity between childhood and adult anxiety disorders. Early childhood histories of separation anxiety disorders in adults with panic disorder have been reported (2). Other studies have linked an early history of separation anxiety disorder to several other adult anxiety disorders such as generalized anxiety disorder and agoraphobia (3, 4) as well as a predisposition to other types of psychopathology (3). Panic disorder, however, has been considered a disorder of adulthood that does not occur in children or adolescents. There is now evidence supReceived
May
22, 1991;
revision
received
Dec. 27, 1991;
accepted
Jan. 24, 1992. From the College of Physicians and Surgeons of Columbia University and the Department of Clinical and Genetic Epidemiology and the Children’s Anxiety and Depression Clinic, New York State Psychiatric Institute. Address reprint requests to Dr. Moreau, Children’s Anxiety and Depression Clinic, 722 West 168th St., Box 60, New York, NY 10032. Supported in part by NIMH grants MH-43878, MH-28274, and
MH-47849. The authors thank Donald Klein, M.D., in the preparation of this manuscript. Copyright © 1992 American Psychiatric
1306
for his helpful Association.
suggestions
and and
panic
adolescents,
to
to suggest
po-
Data Collection: Sixtywere critically reviewed. disorder,
clinical
case
re-
ofpsychiatrically referred chiland school samples of children
for psychiatric of panic,
disorder,
studies
reports
of the
Extending
the
many
fruitful.
to emergency
and
evidence in this
adult
Like
of
biological
Findings: There is strong that its clinical presentation
be extremely
panic disorder, many children and adolescents are brought for the physical symptoms of unrecognized panic disorder. (Am J Psychiatry 1992; 149:1306-13 14)
A
in children in children,
in children. adolescents
basis of panic in adults, and studies of treatment for panic. that panic disorder occurs in children and adolescents and population
Ph.D.
considered an adulthood disorder that does not occur goals were to critically review the available evidence in children and adolescents, to review the limited data
disorder
retrospective
A Review
M. Weissman,
adolescents with panic disorder, studies reports from epidemiologic community
studies
symptoms
Myrna
approaches
tential opportunities for further three articles pertaining to panic ports dren
and Adolescents:
adults
medical
studies with clinics
porting the occurrence of childhood panic attacks with symptoms that are qualitatively distinct from those of separation anxiety disorder. Isolated panic attacks occur in about 10% of adults, and recurrent panic attacks not meeting full diagnostic criteria occur in about 3.6% of adults (5). The rate of full-blown panic disorder is smaller (1.6%). There is increasing evidence that panic attacks and panic disorden are seriously disabling conditions with high morbidity (6-8). Moreover, a childhood onset of these disorders may be especially impairing. A report from the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area (ECA) study (8) indicated that panic disorder with first onset at age 1 7 or younger was associated with greater risk of alcohol abuse, suicidal thoughts, suicide attempts, and use of emergency rooms than onset at age 1 8 or older. Several retrospective reports from adults of their age at onset of panic attacks (9-12) have appeared, suggesting that panic attacks begin in childhood. However, before 1987 there were no published cases of panic attacks or panic disorder based on direct studies of children. In 1987, Casat et al. (13) reported the case of a 12-year-old girl with separation anxiety disorder and mitral valve prolapse. The girl reported symptoms suggestive of adult panic disorder, including tachycardia, sweating, dyspnea, generalized weakness, and “butter-
Am]
Psychiatry
149:10,
October
1992
flies” in her stomach accompanied by school refusal. She later developed fears of crowds, heights, strangers, and being alone. Casat et al. suggested that some children with separation anxiety disorder may develop agoraphobia and panic attacks in adulthood. In 1 989, three separate reports of panic attacks and/or panic disorder in a total of 24 children appeared (14-16). In addition to retrospective reports of adults with panic disorder and clinical case reports of children and adolescents with panic, further evidence that panic attacks and/or panic disorder occur in children and adolescents can be found in clinical case reports of treatment of panic in children and adolescents, in assessments of psychiatrically referred children and adolescents based on structured diagnostic interviews and DSM-III criteria, in reports from epidemiologic community and school samples of children and adolescents, in studies of children and adolescents at risk for psychiatric disorders by virtue of their parents’ psychiatric disorder, and in reports of panic-like symptoms in children and adolescents seen in pediatric services. The purposes of this paper are 1 ) to critically review the available evidence for panic attacks and/or panic disorder in children and adolescents, 2) to review the limited data on the biological basis of panic disorder as it has been studied in children and adolescents, 3) to discuss the possible treatment approaches for panic disorder in this population, and, finally, 4) to suggest potential opportunities for further research on panic disorder in children and adolescents.
REVIEW
OF THE
Retrospective
LITERATURE
Reports
of Adults
With
Panic
Disorder
In several studies of adults with panic disorder (912), the subjects retrospectively reported that their panic disorder began in childhood or early adolescence (figure 1 ). These reports have received little attention. Sheehan et al. (9) studied 100 patients 19-61 years old who had DSM-III panic disorder with agoraphobia. The range of age at onset of panic was 5-58 years; the mean age at onset was 24.1 years. Twenty-six patients reported experiencing symptoms before the age of 20 years: 12 were between 15 and 19 years old, 10 were between 10 and 14 years old, and four were younger than 9 years old. Of interest and concern is the fact that the mean time from onset of symptoms to treatment for the total sample was 12.7 years. Breier et al. ( 1 1 ) reported on age at onset of panic disorder in 60 adults with agoraphobia, mixed phobia, and/or panic disorder diagnosed according to Research Diagnostic Criteria (RDC). Seventeen (28%) of these patients reported that their panic disorder began before they were 20 years old. Eleven patients (18% of the sample) reported that their first panic attack occurred between the ages of 10 and 17, three (5%) reported that their first panic attack was at age 18, and another three (5%) reported that their first attack was at age 19.
Am
] Psychiatry
1 49:1
0, October
1992
FIGURE
DONNA
MOREAU
AND
1. Retrospective
Reports
of Age
MYRNA
M. WEISSMAN
at Childhood
Onset
of Panic
25
20
15 I.
0
10 U 0.
!n
Disorder
in Children
Donna
Moreau,
M.D.,
and
Objective: Panic disorder has been in children or adolescents. The authors’ f or panic attacks and/or panic disorder on the biological discuss
the
basis
possible
ofpanic
treatment
These
and
articles
included
of children and and adolescents, adolescents,
panic-like
as it has for
research disorder
ofchildren in pediatric
been
panic
studied disorder
on panic disorder in children and
histories
of adults
and
adolescents
patients,
with
at risk
family
of panic
is similar disorder
to that
found
to children
and
in adults. adolescents
studies
Conclusions: would
lthough anxiety symptoms are common in children of all ages and both sexes (1), only three anxiety disorders (overanxious disorder, separation anxiety disorder, and avoidant disorder) are classified specifically as disorders of childhood. Family studies and retrospective reports of childhood symptoms by adults with anxiety disorders suggest a continuity between childhood and adult anxiety disorders. Early childhood histories of separation anxiety disorders in adults with panic disorder have been reported (2). Other studies have linked an early history of separation anxiety disorder to several other adult anxiety disorders such as generalized anxiety disorder and agoraphobia (3, 4) as well as a predisposition to other types of psychopathology (3). Panic disorder, however, has been considered a disorder of adulthood that does not occur in children or adolescents. There is now evidence supReceived
May
22, 1991;
revision
received
Dec. 27, 1991;
accepted
Jan. 24, 1992. From the College of Physicians and Surgeons of Columbia University and the Department of Clinical and Genetic Epidemiology and the Children’s Anxiety and Depression Clinic, New York State Psychiatric Institute. Address reprint requests to Dr. Moreau, Children’s Anxiety and Depression Clinic, 722 West 168th St., Box 60, New York, NY 10032. Supported in part by NIMH grants MH-43878, MH-28274, and
MH-47849. The authors thank Donald Klein, M.D., in the preparation of this manuscript. Copyright © 1992 American Psychiatric
1306
for his helpful Association.
suggestions
and and
panic
adolescents,
to
to suggest
po-
Data Collection: Sixtywere critically reviewed. disorder,
clinical
case
re-
ofpsychiatrically referred chiland school samples of children
for psychiatric of panic,
disorder,
studies
reports
of the
Extending
the
many
fruitful.
to emergency
and
evidence in this
adult
Like
of
biological
Findings: There is strong that its clinical presentation
be extremely
panic disorder, many children and adolescents are brought for the physical symptoms of unrecognized panic disorder. (Am J Psychiatry 1992; 149:1306-13 14)
A
in children in children,
in children. adolescents
basis of panic in adults, and studies of treatment for panic. that panic disorder occurs in children and adolescents and population
Ph.D.
considered an adulthood disorder that does not occur goals were to critically review the available evidence in children and adolescents, to review the limited data
disorder
retrospective
A Review
M. Weissman,
adolescents with panic disorder, studies reports from epidemiologic community
studies
symptoms
Myrna
approaches
tential opportunities for further three articles pertaining to panic ports dren
and Adolescents:
adults
medical
studies with clinics
porting the occurrence of childhood panic attacks with symptoms that are qualitatively distinct from those of separation anxiety disorder. Isolated panic attacks occur in about 10% of adults, and recurrent panic attacks not meeting full diagnostic criteria occur in about 3.6% of adults (5). The rate of full-blown panic disorder is smaller (1.6%). There is increasing evidence that panic attacks and panic disorden are seriously disabling conditions with high morbidity (6-8). Moreover, a childhood onset of these disorders may be especially impairing. A report from the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area (ECA) study (8) indicated that panic disorder with first onset at age 1 7 or younger was associated with greater risk of alcohol abuse, suicidal thoughts, suicide attempts, and use of emergency rooms than onset at age 1 8 or older. Several retrospective reports from adults of their age at onset of panic attacks (9-12) have appeared, suggesting that panic attacks begin in childhood. However, before 1987 there were no published cases of panic attacks or panic disorder based on direct studies of children. In 1987, Casat et al. (13) reported the case of a 12-year-old girl with separation anxiety disorder and mitral valve prolapse. The girl reported symptoms suggestive of adult panic disorder, including tachycardia, sweating, dyspnea, generalized weakness, and “butter-
Am]
Psychiatry
149:10,
October
1992
flies” in her stomach accompanied by school refusal. She later developed fears of crowds, heights, strangers, and being alone. Casat et al. suggested that some children with separation anxiety disorder may develop agoraphobia and panic attacks in adulthood. In 1 989, three separate reports of panic attacks and/or panic disorder in a total of 24 children appeared (14-16). In addition to retrospective reports of adults with panic disorder and clinical case reports of children and adolescents with panic, further evidence that panic attacks and/or panic disorder occur in children and adolescents can be found in clinical case reports of treatment of panic in children and adolescents, in assessments of psychiatrically referred children and adolescents based on structured diagnostic interviews and DSM-III criteria, in reports from epidemiologic community and school samples of children and adolescents, in studies of children and adolescents at risk for psychiatric disorders by virtue of their parents’ psychiatric disorder, and in reports of panic-like symptoms in children and adolescents seen in pediatric services. The purposes of this paper are 1 ) to critically review the available evidence for panic attacks and/or panic disorder in children and adolescents, 2) to review the limited data on the biological basis of panic disorder as it has been studied in children and adolescents, 3) to discuss the possible treatment approaches for panic disorder in this population, and, finally, 4) to suggest potential opportunities for further research on panic disorder in children and adolescents.
REVIEW
OF THE
Retrospective
LITERATURE
Reports
of Adults
With
Panic
Disorder
In several studies of adults with panic disorder (912), the subjects retrospectively reported that their panic disorder began in childhood or early adolescence (figure 1 ). These reports have received little attention. Sheehan et al. (9) studied 100 patients 19-61 years old who had DSM-III panic disorder with agoraphobia. The range of age at onset of panic was 5-58 years; the mean age at onset was 24.1 years. Twenty-six patients reported experiencing symptoms before the age of 20 years: 12 were between 15 and 19 years old, 10 were between 10 and 14 years old, and four were younger than 9 years old. Of interest and concern is the fact that the mean time from onset of symptoms to treatment for the total sample was 12.7 years. Breier et al. ( 1 1 ) reported on age at onset of panic disorder in 60 adults with agoraphobia, mixed phobia, and/or panic disorder diagnosed according to Research Diagnostic Criteria (RDC). Seventeen (28%) of these patients reported that their panic disorder began before they were 20 years old. Eleven patients (18% of the sample) reported that their first panic attack occurred between the ages of 10 and 17, three (5%) reported that their first panic attack was at age 18, and another three (5%) reported that their first attack was at age 19.
Am
] Psychiatry
1 49:1
0, October
1992
FIGURE
DONNA
MOREAU
AND
1. Retrospective
Reports
of Age
MYRNA
M. WEISSMAN
at Childhood
Onset
of Panic
25
20
15 I.
0
10 U 0.
!n
